Optimizing HIV prevention for women: a review of evidence from microbicide studies and considerations for gender‐sensitive microbicide introduction

Abstract

IntroductionMicrobicides were conceptualized as a product that could give women increased agency over HIV prevention. However, gender-related norms and inequalities that place women and girls at risk of acquiring HIV are also likely to affect their ability to use microbicides. Understanding how gendered norms and inequalities may pose obstacles to women's microbicide use is important to inform product design, microbicide trial implementation and eventually microbicide and other antiretroviral-based prevention programmes. We reviewed published vaginal microbicide studies to identify gender-related factors that are likely to affect microbicide acceptability, access and adherence. We make recommendations on product design, trial implementation, positioning, marketing and delivery of microbicides in a way that takes into account the gender-related norms and inequalities identified in the review.MethodsWe conducted PubMed searches for microbicide studies published in journals between 2000 and 2013. Search terms included trial names (e.g. “MDP301”), microbicide product names (e.g. “BufferGel”), researchers’ names (e.g. “van der Straten”) and other relevant terms (e.g. “microbicide”). We included microbicide clinical trials; surrogate studies in which a vaginal gel, ring or diaphragm was used without an active ingredient; and hypothetical studies in which no product was used. Social and behavioural studies implemented in conjunction with clinical trials and surrogate studies were also included. Although we recognize the importance of rectal microbicides to women, we did not include studies of rectal microbicides, as most of them focused on men who have sex with men. Using a standardized review template, three reviewers read the articles and looked for gender-related findings in key domains (e.g. product acceptability, sexual pleasure, partner communication, microbicide access and adherence).Results and discussionThe gendered norms, roles and relations that will likely affect women's ability to access and use microbicides are related to two broad categories: norms regulating women's and men's sexuality and power dynamics within intimate relationships. Though norms about women's and men's sexuality vary among cultural contexts, women's sexual behaviour and pleasure are typically less socially acceptable and more restricted than men's. These norms drive the need for woman-initiated HIV prevention, but also have implications for microbicide acceptability and how they are likely to be used by women of different ages and relationship types. Women's limited power to negotiate the circumstances of their intimate relationships and sex lives will impact their ability to access and use microbicides. Men's role in women's effective microbicide use can range from opposition to non-interference to active support.ConclusionsIdentifying an effective microbicide that women can use consistently is vital to the future of HIV prevention for women. Once such a microbicide is identified and licensed, positioning, marketing and delivering mic...

Why interventions to prevent intimate partner violence and HIV have failed young women in southern Africa

“…They argue the failure of PrEP interventions for young women is the result of the lack of consideration of local contextual factors, including social norms around sexuality and broader structural barriers making it difficult for young women to adhere to PrEP. Similar findings of low adherence in younger women were described in the topical microbicide and vaginal ring trials .…”

Development and initial validation of a simple tool to screen for partner support or opposition to HIV prevention product use

“…In sub-Saharan Africa, 56% of new infections were in women, and 67% of new infections were comprised of young women aged 15–24 [ 5 ]. Research suggests that women’s continued risk of HIV stems from inequitable gender norms and the threat of intimate partner violence (IPV) that both promote high-risk sexual relationships and limit options for HIV prevention behaviors [ 6 , 7 ].…”

The influence of social constructs of hegemonic masculinity and sexual behaviour on acceptability of vaginal microbicides in Zambia

“…The influence of partners in decisions to use the gel has been reported by other studies (Doggett et al, 2015;Jones et al, 2008;Kelly et al, 2015;Koo et al, 2005;C. M. Montgomery et al, 2008;Moon et al, 2002;Veldhuijzen et al, 2006;Venables & Stadler, 2012;C.…”

“…Woodsong et al, 2013). One prominent issue from these studies is the role male partners play in the use of vaginal microbicide (Doggett et al, 2015;Jones, Weiss, Chitalu, Bwalya, & Villar, 2008;Koo, Woodsong, Dalberth, Viswanathan, & Simons-Rudolph, 2005;Lanham et al, 2014; C. M. Montgomery et al, 2010; C. M. Montgomery et al, 2008;Moon, Khumalo-Sakutukwa, Heiman, Mbizvo, & Padian, 2002;Venables & Stadler, 2012;C. Woodsong & Alleman, 2008;Cynthia Woodsong & Holt, 2015; C. Woodsong et al, 2013).…”

“…Several studies have debated the factors that influence consistent use and generally acceptability of vaginal microbicides (Coly & Gorbach, 2008;Doggett et al, 2015;Domanska & Teitelman, 2012;Mantell et al, 2005;C. Woodsong et al, 2013).…”